COVID-19 β€’ WITH MAITRY PATEL, CCPA

Maitry Patel, Canadian Radiation Oncology PA on the Frontlines of COVID-19

About COVID-19

COVID-19 is caused by a member of the coronavirus family, a strain never seen before late 2019. Due to its ability to transmit within communities (without any known exposure or personal travel history), it is a challenge to control this with immediate affect.

COVID-19 in Radiation Oncology

I work with oncology patients, who are one of the highest risk populations for contracting this (others being elderly, immunocompromised, etc.). Radiation oncology patients undergo daily treatment and if someone is suspected of having COVID-19, their treatment can be halted or delayed, affecting their cancer outcome.

Serving on the RMP Steering and Pandemic Planning Committee in conjunction with Cancer Care Ontario has given me an opportunity to bring a true multidisciplinary approach to this rapidly evolving situation. We are being vigilant with screening to keep PMH COVID-free.

Screening Cancer Patients for COVID-19

At door screening, we go through a list of symptoms (cough, fever, runny nose, sore throat, dyspnea) +/- travel history. If visitors are screen positive, they are not allowed to enter and must present to a COVID-assessment centre set up by Toronto public health. Screen-positive patients undergo secondary assessments, where nasopharyngeal swabs may be obtained to rule out. Our current policy is β€œCOVID-positive till proven otherwise.”

As a PA, I am also involved in triaging of new incoming oncology referrals.

We classify patients in A, B, and C categories:

This allows us to safely care for oncology patients while deferring treatments that can wait without leading to tumor progression

About Maitry Patel, CCPA

Maitry is a Canadian Certified Physician Assistant working in Radiation Oncology. She is a McMaster PA graduate.

Learn about being a Radiation Oncology PA

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For the last 4 weeks, I have been conducting virtual clinics from home 2-3 days/week. My patients appreciate avoiding the hospital, yet knowing that their cancer care remains my top priority amidst a pandemic. However, working from home (WFH) is tiring [and fattening]. So here are some WFH tips for HCPs: 𝟏. π’πžπ­ 𝐚𝐧 𝐚π₯𝐚𝐫𝐦: for my normal work schedule. I have an hour commute. I still wake up at the same time. But I use that 1-hour to: 𝟐. π„π±πžπ«πœπ’π¬πž: on the treadmill as I virtually attend COVID-19 planning meetings using Microsoft Teams so I can type my input while I workout. πŸ‘. 𝐃𝐨 𝐚𝐩𝐩𝐞𝐚𝐫𝐚𝐧𝐜𝐞-π›πšπ¬πžπ 𝐭𝐚𝐬𝐀𝐬: after shower, I get dressed as if I were going to work. This seems simple but it’s crucial. When I work from my PJs, I accomplish less. This step also ensures that I feel like I am looking after myself. πŸ’. π‚π«πžπšπ­πž 𝐚 𝐰𝐨𝐫𝐀𝐬𝐩𝐚𝐜𝐞: for 3 weeks, I worked from my bed. I had neck pain, felt lousy and lost my motivation. I now have a corner dedicated as my office (with a chair, table and dΓ©cor that makes me feel like I’m in Paris). It’s crucial to ensure the natural lighting is right so my eyes don’t strain from looking at the computer for 8-12 hours. πŸ“: π“πšπ€πž π›π«πžπšπ€π¬: I physically go downstairs for lunch so I am not β€œeating at my desk.” My mother reminds me to hydrate myself and I also sneak in a PM snack. Taking breaks does not mean keeping up with every COVID related news. πŸ”: π‚π«πžπšπ­πž 𝐭𝐫𝐚𝐧𝐬𝐒𝐭𝐒𝐨𝐧 𝐭𝐨 𝐚𝐧𝐝 𝐟𝐫𝐨𝐦 𝐰𝐨𝐫𝐀: when I wrap up for the evening, I change into my PJs, do my chores, watch a movie and stretch. It would be easy for me to get carried away and keep doing my endless work till 9 pm. But I would burn out. πŸ•: 𝐏π₯𝐚𝐧: when I go into work, I print clinic lists, pt info, update my calendar, clean my inbox and connect with my coworkers physically so we continue to maintain sanity. At home, I ensure my out-of-office is in place so I am easily reachable. This has reduced the amount of unnecessary emails and worrisome calls. Write below how you make WFH work!Β And most of all, know that β€œπ•€π•₯’𝕀 π•˜π• π•Ÿπ•Ÿπ•’ 𝕓𝕖 π• π•œπ•’π•ͺ!”

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You have all seen a version of this curve of COVID-19 🦠 case loads by now. It’s called β€œflattening the curve”. There are many variations but there are some key similarities: β€’ β€’ 1. They have no numbers on the axes. They don’t give you an idea how many cases it takes to overwhelm the medical system, and over how many days the epidemic will play out. Every system, every country has a different capacity so the curve can be assigned different numbers. β€’ β€’ 2. They suggest that currently, the medical system can deal with a large fraction (like maybe 2/3, 1/2 or 1/3) of the cases, but if we implement some mitigation measures, we can get the infections per day down to a level we can deal with. More on mitigation measures on slide 2. β€’ β€’ An important part of the equation are ventilators. Most of the critically ill COVID-19 cases die of an infection of the lungs that makes it impossible to breathe and even destroys so much tissue that the blood can no longer be sufficiently oxygenated. These patients need intubation, mechanical ventilation to give them a chance of survival, or even an ECMO machine. β€’ β€’ In response to all of this, a review by Chen Shen, Nassim Nicholas Taleb and Yaneer Bar-Yam points out that this does not mean that we only have a choice between perpetual intervals of lockdowns and continued spread of the disease in the intervals, until we develop an effective vaccine or course of treatment. There are some transition options β€’ β€’ Slide 2 shows mitigation strategy scenarios for showing critical care (ICU) bed requirements, as outlined by Ferguson et al. The black line shows the unmitigated epidemic. The green line shows a mitigation strategy incorporating closure of schools and universities; orange line shows case isolation; yellow line shows case isolation and household quarantine; and the blue line shows case isolation, home quarantine and social distancing of those aged over 70. The blue shading shows the 3-month period in which these interventions are assumed to remain in place. β€’ β€’ So let’s not just flatten the curve, let’s SQUASH IT! πŸ”¨

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Above are 10 radiolographical images of COVID patients obtained from https://radiopaedia.org/articles/covid-19-3?lang=us#image_list_item_52143675 by Dr CM Moore, Dr DJ Bell, et al. β€’ β€’ Slide 1: The 360Β° volume rendering technique (VRT) shows extensive bilateral lung damage. On CT, there are pronounced bilateral confluent ground-glass opacities, mostly in the periphery of the lungs. β€’ β€’ Slide 2: The interesting point of this case is that there is a large unilateral area of air space consolidation involving the right lower lobe but the ground glass and/or consolidative opacities of COVID-19 pneumonia are most commonly bilateral. β€’ β€’ Slides 3 to 9: CT axial and coronal images of many patients with ARDS secondary to COVID infection. The primary findings on chest CT have been reported as: ground glass opacities (GGO) in all hospitalised patients, crazy paving appearance (GGOs and inter/intralobular septal thickening), and air space consolidation. No mediastinal lymphadenopathy has been seen in review of images so far. β€’ β€’ In the right clinical context, large ground-grass opacity lesions, predominantly in the peripheral and posterior lungs on CT, are diagnostic of COVID-19 pneumonia, even if PCR results are not back or the result is a potential false negative.. Note the absence of mediastinal adenopathy which is not usually seen in COVID-19 and should suggest the presence of superimposed infection, e.g. bacterial pneumonia, or preexisting/new malignancy. β€’ β€’ β€’ Slide 10: Plain X-ray obtained at onset of triage in ER of a patient who subsequently tested positive for COVID-19. β€’ β€’ @thepamama & @docfuji, this post is for you guys!

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